Forever Home Care, LLC

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours of the date of referral for 1 (P-2) record in which start of care services was delayed, from a total of 9 sampled records reviewed, resulting in delay in needed care and services and the potential for declining health status and unmet care needs (G514); failed to ensure the comprehensive assessment accurately reflected the patient’s current health status and needs in 1 (P-4) of 9 total sampled records reviewed (See G 528); failed to perform clinical assessments as ordered to meet the needs of the patient in 1 (P-4) of 1 record reviewed with a significant change in condition, from a total sample of 9 records reviewed (See G 534); and failed to ensure a Registered Nurse had performed a medication review at the start of care and failed to perform a medication reconciliation upon a resumption of care after a hospital discharge in 1 (P-4) of 2 records reviewed with therapy services ordered (See G 536); failed to ensure the Comprehensive Assessment was updated and completed at the time of discharge from the agency’s services in 1 (P-2) of 4 discharged records, from a total of 9 sampled records reviewed, resulting in no indication of the patient’s progression towards their identified goals and the potential for unmet continuing care needs. (G550). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR §484.55 Comprehensive Assessment of Patients.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to provide documentation that it had participated in the community based full-scale exercise required every two years, resulting in the potential for patients and staff not to be properly prepared in the event of an actual emergency. Findings include: On 5/14/24, review of the Agency’s Emergency Preparedness (EP) binder found no evidence that the Agency had participated in any of the required full-scale community-based exercises over the last two years. Documentation of an actual community emergency or event that could be substituted for the above exercise was not found. This finding was reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 5/15/2024 at 1:45 PM.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to utilize collected data in its Quality Assessment and Performance Improvement (QAPI) program to quantitatively track and trend specified patient quality control measures, resulting in the potential for poor patient outcomes due to the provision of substandard care for all 20 patients currently serviced by this Agency. Findings include: On 5/15/2024, review of the Agency’s QAPI program data found no evidence from the last 3 years concerning the evaluation of program data that was tracked and trended to ascertain progress made (or lack of) towards pre-established goals developed by the Agency’s Governing Body. This finding was reviewed and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) on 5/15/24 at 1:55 PM. Both acknowledged this failed to meet its policy referenced below. Agency Policy: “Quality Assessment and Performance Improvement (QAPI) Plan” (dated 01/2024) stated, “To monitor and assess results, findings are used to identify and support the implementation of PI (performance improvement) projects... For each process identified to be improved, mechanisms to identify levels, patterns or trends in that process that will trigger further evaluation of the process will be identified.””

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to develop a Quality Assessment Performance Improvement (QAPI) program that documented any performance improvement projects, the reasons for conducting these projects along with measurable tracking and trending measures to ascertain progress achieved during the last three years, resulting in the Agency’s inability to improve in patient care, health outcomes, patient safety, and overall quality of care for all 92 patients that received services with the past 12 months. Findings include: During an interview on 5/15/24 at 1:45 PM., the Administrator (Staff A) was queried about documentation of the Agency’s QAPI Program and Performance Improvement Projects (PIP’s), reasons for conducting the projects along with measurable progress achieved. Staff A was unable to provide documentation of any PIP’s during the last 3 years. The Agency failed to follow its policy referenced below. Agency Policy: “Quality Assessment and Performance Improvement (QAPI) Plan” (dated 01/2024) stated, “The organization (Agency) defines goals, outcomes, and measures that are included in the (QAPI) program and the data that will be used to support Agency’s performance improvement (PI) activities.””

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on interview and record review, the Agency failed to ensure the Skilled Nurse prepared clear written patient care instructions for the home health aide regarding client needs and frequency of visits in 1 (P-2) record in which Home Health Aide services were ordered, from a total of 9 sampled records reviewed, resulting in the potential for missed visits, lack of needed assistance with grooming and unmet care needs. Findings include: P-2: The patient’s start of care was 3/14/24 with diagnoses that included Heart Failure, Pressure Sore, Chronic Lumbago and End-Stage Renal Disease. During the clinical record review on 5/14/24 at 9:00 a.m., it was noted that the Plan of Care (POC) ordered Home Health Aide (HHa) services to be provided at a frequency of 2x/wk. x 8 wks. The Aide Plan of Care however, indicated HHa visits to be provided at a frequency of 2x/wk. x 6 weeks. This inconsistency would cause HHa to end services earlier than specified schedule. These findings were reviewed with and confirmed by the Administrator and Clinical Manager during an interview on 5/15/24 at 11:35 a.m.”

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the potential for interruption in continuity of care and unmet care needs. Findings include: On 5/15/24, review of CMS (Centers for Medicare & Medicaid) Form 1572 noted under section 11 of “Services Provided” that all services furnished by the agency incorporated an “Under Arrangement” or contracted staff. No evidence was found that indicated the agency had provided at least one of the services directly as required. Further, no evidence was found during the survey which allowed contracted staff to be used on a temporary basis such as an unexpected staffing shortage. This finding was reviewed and confirmed by the agency Administrator during an interview on 5/15/24 at 1:10 PM.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours of the date of referral for 1 (P-2) record in which start of care services was delayed, from a total of 9 sampled records reviewed, resulting in delay in needed care and services and the potential for declining health status and unmet care needs. Findings include: The patient’s start of care (SOC) was 3/14/24 with diagnoses that included Heart Failure, End-Stage Renal disease and Pressure Sore. The referral for home care was dated 3/7/24 and ordered Skilled Nursing, Physical Therapy, Medical Social Work and Home Health Aide services to be provided. During the clinical record review on 5/14/24 at 9:00 a.m., it was noted that the Initial SOC Assessment was conducted one week after the date of the referral. Additionally, there was no documented rationale for the delay in needed care and services. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 5/15/24 at 11:35 a.m.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status and needs in 1 (P-4) of 9 total sampled records reviewed, resulting in incomplete clinical information towards determining the needs of these patients. Findings include: P-4: The start of care (SOC) date to home care was 10/19/23, with diagnoses which included hypertensive heart disease, congestive heart failure (CHF), diabetes-type 2, and wound to left great toe. On 5/14/24, review of the SOC comprehensive assessment, dated 10/19/23 noted under the “Primary Diagnosis and Other Diagnoses” section, that 21 of 21 listed diagnoses had the same date of exacerbation/onset as being 10/19/23, and 4 of 4 additional diagnoses had the same date of exacerbation/onset as being 10/6/23. When cross referenced with the physician referral for home care dated 10/10/23, this information was found to be inaccurate. Further, there were no documented prior treatments, outcomes, or detailed history to give context to the level of clinical needs of P-4 for clinical staff to be prepared for. The above findings were reviewed and acknowledged by the agency Administrator (Staff A) and Clinical Manager (Staff B) on 5/15/24 at 1:20 PM. The agency failed to adhere to its policy referenced below. Agency Policy: “Assessments: Initial Comprehensive” (dated 01/2024) page 1 stated, “The assessment will reflect the patient’s current health status and include information to demonstrate the patient’s progress toward achievement of desired outcomes. The Initial Comprehensive Assessment also includes: Relevant medical history; Risk for hospitalization, ...””

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the patient’s needs concerning wound care and diagnosis of congestive heart failure (CHF) were adequately met in the patient’s home for 1 (P-4) of 1 record reviewed with a significant change in condition, from a total of 9 records reviewed, resulting in unmet care needs and a poor clinical outcome. Findings include: P-4: The start of care (SOC) date to home care was 10/19/23, with diagnoses which included hypertensive heart disease, congestive heart failure (CHF), diabetes-type 2, and wound to left great toe. The only service ordered was Physical Therapy (PT), which was ordered to provide a visit frequency of 2W4 (bi-weekly for 4 weeks), 1W4. During record review on 5/14/24, it was noted that the initial SOC comprehensive assessment performed by Physical Therapy (PT), documented the following: “59-year-old male with multiple co-morbidities with recent hospital admit for CHF and fluid retention. He has been on chemotherapy of metastatic cancer. Cut on tip of the left big toe ... Laceration measurements (L/W/D) 2.5 x 1.5 x0.1 cm. Wound care performed per following orders: Irrigate with NS (normal saline), Pat dry with gauze, apply mupirocin (antibiotic) ointment 2% to wound bed, edges and surrounding skin, cover with 2x2 sterile gauze, wrap with stretch gauze bandage, secure with tape.” PT had documented P-4 was diabetic with neuropathy (nerve damage caused by the diabetes) with recent blood sugar of 170 mg/dl. In addition, PT documented the patient was positive for CHF of dependent pitting edema (swelling) with no level of edema assessed. On 10/21/23 through 10/25/23, P-4 was hospitalized for shortness of breath (SOB). The resumption of care (ROC) visit (dated 10/26/23) performed by PT, documented the wound had no improvement from the above measurements and P-4’s edema was 2+ in lower extremities with left being greater than the right lower leg. PT documented P-4 was discharged from the hospital for “recent repeated hospital admit for arrythmia, CHF and fluid retention.” Further review of the following PT visit notes revealed a significant physical decline in P-4’s ambulation starting with the first visit (10/28/23) after the ROC above. 10/28/23: ambulation was 84 feet with no wound assessment/treatments provided, and no CHF assessment was performed. 10/31/23: ambulation was 51 feet with no wound assessment/treatments provided, and no CHF assessment was performed. 11/2/23: ambulation was 50 feet with no wound assessment/treatments provided, and no CHF assessment was performed. However, the physician was notified of increased SOB and that the physician would follow-up directly. 11/7/23: ambulation distance was not assessed with no wound assessment/treatments provided, and no CHF assessment was performed. Further review of the medical record noted on 11/7/23, that the physician ordered an additional discipline of Skilled Nursing (SN) to perform an evaluation visit due to “patient having tachycardia (elevated heart rate), uncontrolled BP and indications of fluid retention.” 11/9/23: ambulation was 32 feet with no wound assessment/treatments provided, and no CHF assessment was performed while patient required “multiple rest breaks in order to prevent over exertion.” 11/15/23: ambulation was 37 feet with no wound assessment/treatments provided, and no CHF assessment was performed. 11/16/23: ambulation was 37 feet with no wound assessment/treatments provided, and no CHF assessment was performed. Additional review noted SN still did not evaluate the patient from the above order (11/7/23) until fifteen days later on 11/22/23. SN evaluated P-4 but failed to obtain a weight, edema measurements, wound acknowledgement (or lack of), and oxygen blood level. No documentation was found in the medical record explaining why SN failed to evaluate the patient timely given the recent hospitalizations and actively declining clinical status. PT also performed a visit on 11/22/23 and documented the patient had an increase of edema to +3 pitting and “Patient’s son stated that MD has given up on him and are just doing palliative management... No DNR, Full code.” The above findings were reviewed and acknowledged by the agency Administrator (Staff A) and Clinical Manager (Staff B) on 5/15/24 at 1:25 PM. Both agreed SN failed to assess and furnish the order as directed and PT should have assessed the patient needs concerning CHF, wound care, and diabetic management prior to being informed of P-4’s palliative care status on 11/22/23.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that a Registered Nurse (RN) had performed a medication reconciliation review as required (P-3, P-6) at the time, from a total sample of 9 records reviewed, resulting in the potential for harmful medication effects for all 20 patients currently receiving services from this agency. Findings include: P-6: The start of care (SOC) was dated 3/4/24, with diagnoses of surgical aftercare, ulcer, and hypertension (HTN). During record review on 5/13/24, it was noted that the SOC Comprehensive Assessment documented under (M2001) Drug Regimen Review, “Potential clinically significant medication issues were found.” Under (M2003) Medication Follow-up, “Physician was notified.” There was no drug reconciliation, or what actions were taken from the physician notification, documented in the record. The medication profile dated 3/4/24, asked if the physician was notified regarding medication discrepancies and indicated “No, due to no issues found.” These findings were reviewed with and acknowledged by the administrator (Staff A) and the Clinical Manager (Staff B) during an interview on 5/15/24 at 1:00 p.m. P-3: The patient’s SOC was 4/27/24 with diagnoses that included Bipolar Depression. The referral for home care instructed on the need for medication/medical management. During the record review on 5/14/24 at 10:55 a.m., it was noted that the SN conducted the Initial Comprehensive Assessment. Upon further review, it was revealed that the Assessment was incomplete and void of the required drug review to ascertain any untoward findings. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 5/15/24 at 11:50 a.m.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the Comprehensive Assessment was updated and completed at the time of discharge from the agency’s services in 1 (P-2) of 4 discharged records, from a total of 9 sampled records reviewed, resulting in no indication of the patient’s progression towards their identified goals and the potential for unmet continuing care needs. Findings include: P-2: The patient’s start of care was 3/14/24 with diagnoses that included Heart Failure, Chronic Lumbago, Pressure Sore and End-Stage Renal Disease. During the clinical record review on 5/14/24 at 9:00 a.m., it was noted that the patient was discharged from the agency’s services on 5/9/24. At the time of this review, the Discharge Oasis/Comprehensive Assessment had not been initiated/completed. These findings were reviewed with and confirmed by the Administrator and Clinical Manager during an interview on 5/15/24 at 11:35 a.m.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included reportable pain parameters in which to notify the physician, objectively measurable goals specific to the individualized needs of the patient in 5 records (P-1, P-2, P-5, P-6, P-7,) and failed to include safety precautions for 1 record (P-7), from a total sample of 9 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-6: The start of care (SOC) was dated 3/4/24, with diagnoses of surgical aftercare, ulcer, and hypertension (HTN). During record review on 5/13/24, it was noted that the plan of care (POC) dated 3/4/24, failed to include objectively measurable goals specific to the individualized needs of the patient. For example, one goal stated, “The patient/caregiver will verbalize understanding of skin conditions that must be reported to skilled nursing (SN) or the physician immediately.” Another stated, “Caregiver will verbalize understanding of proper orientation techniques to use when patient becomes disoriented” It was unclear how these goals could be objectively measured to ascertain progress toward the goals. P-7: The SOC was dated 9/30/23, with diagnoses of HTN, heart disease and diabetes. During record review on 5/13/24, it was noted that the POC dated 9/30/23, did not have diabetic safety precautions documented. The POC also failed to include objectively measurable goals specific to the individualized needs of the patient. For example, one goal stated, “The patient/caregiver will verbalize understanding of proper diabetic foot care by 5/14/24.” Another stated, “Patient will verbalize an understanding of energy conserving measures by.....” It was unclear how these goals could be objectively measured to ascertain progress toward the goals. These findings were reviewed with and acknowledged by the administrator (Staff A) and the Clinical Manager (Staff B) during an interview on 5/15/24 at 1:00 p.m. P-1: The patient’s start of care (SOC) was 1/4/24 with diagnoses that included Spondylosis and lower back pain. During the clinical record review on 5/13/24, it was noted that all the patient’s listed diagnoses reflected an exacerbation date of 1/4/24 (date of admission), however, there were no interventions to manage them. The patient complained of 5/10 pain upon admission. Review of the plan of care (POC) revealed that there were no reportable pain parameters in place in which to notify the Physician. Further, there were no associated pain goals. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 5/15/24 at 11:12 a.m. P-2: The patient’s SOC was 3/14/24 with diagnoses that included Chronic Pain, Pressure Sore, Heart Failure and End Stage Renal Disease. During the record review on 5/14/24 at 9:00 a.m., it was noted that all the patient’s listed diagnoses had an exacerbation date of 3/6/24. There were no interventions to address the exacerbated conditions. Throughout the course of care, the clinical record revealed the patient complained of pain at levels 7/10 and 5/10. The POC was void of reportable pain parameters in which to notify the Physician. Additionally, there were no associated pain goals. During the record review, it was noted that the patient went to dialysis 3 times per week. The POC failed to include the location of the site and any necessary precautions. The above findings were reviewed with and acknowledged by the Administrator and Clinical manager during an interview on 5/15/24 at 11:35 a.m. P-5: The start of care (SOC) date for home care was 1/4/24, with diagnoses which included radiculopathy-lumbar region, chronic kidney disease, and congestive heart failure. On 5/14/24, review of an updated Plan of Care (POC) (dated 4/11/24) due to a post-hospitalization/resumption of care concerning flu, noted the additional ordered service of Skilled Nursing (SN). Further review of the SN goals (27 of 27) for P-5 noted a failure to include objectively measurable goals specific to the needs of the patient. Examples of the goal documentation are: “Patient will be free from signs and symptoms of respiratory distress during the episode; Patient will not develop any signs or symptoms of dehydration during the episode; Patient will verbalize an understanding of energy conserving measures by 04/25/2024 ...” These findings were reviewed and acknowledged by the Administrator and Clinical Manager during an interview on 5/15/24 at 1:25 PM. The agency failed to ensure SN provided specific measurable goals pertinent to the needs related to P-5’s post-hospital discharge.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient was advised of the ordered discipline’s visit frequency prior to the provision of care and services for 1 (P-2) patient ordered to receive home health services, from a total of 7 sampled records reviewed, resulting in the patient not having a say in the planning of care. Findings include: P-2: The patient’s start of care was 3/14/24 with diagnoses that included Pressure Sore, Heart Failure and End-Stage Renal Disease. During a review of the clinical record on 5/14/24 at 9:00 a.m., it was noted that the patient’s Consent for Treatment was void of the disciplines who would be providing services along with their ordered visit frequencies. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 5/15/24 at 11:35 a.m.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure Skilled Nursing and Medical Social Work services were provided as ordered by the Physician and the Plan of Care for 2 (P-1, P-2) patients who required the needed services, from a total of 9 sampled records reviewed, resulting in the potential for unmet care needs and lack of needed resources. Findings include: P-1: The patient’s start of care (SOC) was 1/4/24 with diagnoses that included Spondylosis and Low back pain. The referral for home care ordered Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT) and Home Health Aide (HHa) services to be provided. The record reflected that the patient was discharged from the Agency’s services on 5/1/24. At the time of this review on 5/13/24, SN services had not been provided. Further, there was no documented evidence that the patient declined the needed service. These finding were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 5/15/24 at 11:12 a.m. P-2: The patient’s SOC was 3/14/24 with diagnoses that included Chronic Lumbago, Pressure Sore and Heart Failure. The referral for home care ordered SN, PT, HHa and Medical Social Work (MSW) services to be provided. During the record review, it was noted that MSW services had not been provided as ordered. Further, there was no evidence that the patient declined the needed/ordered service. These findings were reviewed with and acknowledged by the Administrator and Clinical Manger during a interview on 5/15/24 at 11:35 a.m.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record was complete and included clinical notes, discharge summary, and required comprehensive assessments for 2 (P-1, P-3) of 9 records reviewed, resulting in the physician not having a clear and concise clinical picture of the patient’s health status, progression towards goals, resulting in an incomplete clinical record and the potential for unmet care needs. Findings include: P-1: The patient’s start of care (SOC) was 1/4/24 with diagnoses that included Spondylosis and Low back pain. The referral for home care ordered Physical Therapy (PT) services to be provided at a frequency of 1x/wk. x 9 wks. During the clinical record review on 5/13/24, the following was noted: PT visit notes dated 4/3/24, 4/8/24 and 4/15/24 all indicated, “Not Started.” The PT Re-Evaluation dated 4/24/24 indicated, “Not Started.” The PT Discharge Oasis dated 5/1/24 also revealed, “Not Started.” All the above visit notes, re-evaluation and discharge oasis were not available for review as they had not been initiated/completed at the time of this record review. These findings were reviewed with and confirmed by the Administrator and Clinical Manager during an interview on 5/13/24. The Administrator stated the agency has had problems with disciplines submitting timely documentation. P-3: The patient’s SOC was 4/27/24 with diagnoses that included Bipolar Disorder and Depression. During the clinical record review on 5/14/24 at 10:55 a.m., it was noted that the Plan of Care had not been initiated/completed. There was no guidance in which to direct the disciplines course of care. Additionally, the Initial Comprehensive Assessment, to be completed by the Skilled Nurse was noted to be incomplete. Further, Skilled Nursing visit note 5/3/24 was incomplete, and the Skilled Nursing visit note dated 5/10/24 was blank. These findings were reviewed with and confirmed by the Administrator and Clinical Manager during an interview on 5/15/24 at 11:50 a.m. No response was offered.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a detailed discharge summary was complete and sent to the physician within 5 days of the date of discharge in 4 (P-1, P-2, P-4, P-7) of 4 discharge records, from a total sample of 9 records reviewed, resulting in a lack of information to ensure continuity of care. Findings include: P-7: The start of care (SOC) was dated 9/30/23, with diagnoses of hypertension (HTN) and heart disease. During record review on 5/13/24, it was noted that the record contained a discharge summary dated 9/30/23. There was no documented evidence in the record that the discharge summary was sent to the patient’s physician. These findings were reviewed with and acknowledged by the administrator (Staff A) and the Clinical Manager (Staff B) during an interview on 5/15/24 at 1:00 p.m. P-4: The admit date to home care was 10/19/23, with diagnoses which included hypertensive heart disease, congestive heart failure (CHF), diabetes-type 2, and wound to left great toe. During record review on 5/14/24, it was noted P-4 was transferred to the hospital for fluid overload symptoms related to CHF on 10/21/23. On 12/1/23, P-4 was transferred to the hospital for CHF symptoms. Further review of the record noted skilled nursing (SN) discharged the patient from the agency on 11/30/23 and documented the following: “Patient was hospitalized on 11/20/23 and passed away.” In addition, the discharge summary failed to document any patient care findings provided throughout the certification episode other than a medication list and a check box stating that P-4 was “Deceased” the day prior to the transfer summary noted on 12/1/24. During an interview with the agency Administrator (Staff A) and Clinical Manager (Staff B) on 5/15/24 at 1:05 PM., a request was made to review the dates of when the transfer summaries and discharge summary were sent to the physician for review. No evidence was found in the medical record of when the above summaries were sent to the physician. Both noted the discharge summary performed by SN was inaccurate and failed to meet agency expectations and its policies referenced below. Agency Policy: “Discharge Summary” (dated 01/2024) page 37 stated, “The Discharge Summary will include, but is not limited to: Status of problems identified throughout the course of care... Summary of care and services provided... A copy of the Discharge Summary will be sent to the physician within 5 business days of discharge.” Agency Policy: “Transfer Criteria” (dated 01/2024) page 84 stated, “Transfer Summary will be provided to receiving organization with two (2) business days of transfer when Agency is actively involved in the transfer process.” P-1: The patient’s start of care (SOC) was 1/4/24. The certification period of review was 3/4/24 through 5/1/24 with diagnoses that included Spondylosis and Lower Back Pain. The referral for home care ordered Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), and Home Health Aide (HHa) services to be provided. During the record review on 5/13/24, it was noted that the patient was discharged from the agency’s services by the PT on 5/1/24. No Discharge Summary had been completed at the time of this review. These findings were reviewed with and acknowledged by the Administrator and Clinical Manger during an interview on 5/15/24 at 11:12 a.m. P-2: The patient’s SOC was 3/14/24 with diagnoses that included Chronic Lumbago, Pressure Sore, Heart Failure and End-Stage Renal Disease. During the record review on 5/14/24 at 9:00 a.m., it was noted that the patient was ordered to receive (SN), (PT), Medical Social Work (MSW) and (HHa) services. The patient was discharged from SN services on 5/2/24. The SN Discharge Summary dated 5/2/24, was void of any information regarding the status of the patient’s wound. The section titled, “Care Coordination” was left blank. Additionally, there was no documented evidence that the summary had been forwarded to the Physician within 5 days of the date of discharge. these findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 5/15/24 at 11:35 a.m.”